IMHO Project Proposal Request Format IMHO is able to do its valuable work through reputable local partners. Proposal requests sent to IMHO should follow the format outlined below. It needs to be sent on the original letterhead of the recipient organization/individual and signed. The request may be forwarded by email to contact@theimho.org for preliminary review. 1. Please fill out the attached Overview of Proposal Plan as completely as possible. 2. Please include copies of the following supporting documents along with your application: a. Charity status certificate of the recipient organization and tax return from the last 3 years, if available. b. Provide information on any of the projects completed by your organization or by you in the recent past. State the names of your current partners. c. Bank account information (including bank name, address, account number and sorting/swift code) 3. The recipient agency or individual needs to provide a signed document to IMHO that they have not received any other funds towards the particular project being supported by IMHO to prevent any duplication of funding. 4. With regards to follow‐up and project accounting, the recipient agency or individual must send: a. Acknowledgement of receipt of donation. b. Quarterly reports to the IMHO Board of Directors (exact timeframe depends on the full project/program timeline). Please use the Project Report Form provided by IMHO. c. Any future plans for expansion or scaling up (if any). Please note, any significant changes to the project/program as outlined in your proposal, including project budget, must be pre‐approved by the IMHO Board of Directors. Thank you for working with us. Please contact us if you have any questions or need any clarification, or if you would like to discuss the details of your application. Sincerely, IMHO Board of Directors Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
Overview of Proposal Plan Title of Project/Program:________________________________________________________________ Name and Address of Organization:_______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Will this organization be implementing the project (if not, please specify who will)?:_________ ______________________________________________________________________________ Organization Website (if any):____________________________________________________________ Contact Name(s) of Key Person(s):_________________________________________________________ Phone Number(s):_______________________________________________________________ Email(s):_______________________________________________________________________ Fax:___________________________________________________________________________ Describe your organization (mission, major programs, year established, etc):______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Brief Description of Project:______________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
_____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Annual Operating Budget:__________________________________________________________ Number of total paid full‐time/part‐time staff:_________________________________________ Need Statement:_______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Target Population/Beneficiaries: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Project Goals & Objectives (please fill in as many as needed): Goal 1:________________________________________________________________________ ______________________________________________________________________________ Objective 1:______________________________________________________________ ________________________________________________________________________ Goal 2:________________________________________________________________________ Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
______________________________________________________________________________ Objective 2:______________________________________________________________ ________________________________________________________________________ Goal 3:________________________________________________________________________ ______________________________________________________________________________ Objective 3:______________________________________________________________ ________________________________________________________________________ Goal 4:________________________________________________________________________ ______________________________________________________________________________ Objective 4:______________________________________________________________ ________________________________________________________________________ Goal 5:________________________________________________________________________ ______________________________________________________________________________ Objective 5:______________________________________________________________ ________________________________________________________________________ Proposed Timeline of Project:____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What difficulties/challenges do you foresee in implementing this project?:________________ Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
______________________________________________________________________________ ______________________________________________________________________________ Name and Role of Any Other Organizations Involved (if you have submitted this project proposal to other agencies/individuals, please inform us): 1.___________________________________________________________________________________ _____________________________________________________________________________________ 2.___________________________________________________________________________________ _____________________________________________________________________________________ 3.___________________________________________________________________________________ _____________________________________________________________________________________ 4.___________________________________________________________________________________ _____________________________________________________________________________________ 5.___________________________________________________________________________________ _____________________________________________________________________________________ Long‐term Sustainability:________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please Explain Any Ongoing Operating Expenses (and specify who you expect to fund): _______ ______________________________________________________________________________ Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
______________________________________________________________________________ ______________________________________________________________________________ Please Explain Any Staffing Needs (if any) & Plans for Staff Training (if any):________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Type of Support Requested from IMHO (check one or more boxes): Funding Equipment/Supplies Trainings Other Description of Support Requested:________________________________________________________ _____________________________________________________________________________________ Overview of Project/Program Budget:_____________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you have a bank account or a fiscal sponsor? Please provide the following information on your bank account or your fiscal sponsor’s bank account? Account Name:__________________________________________________________ Account Number:________________________________________________________ Sort Code:______________________________________________________________ SWIFT:_________________________________________________________________ Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
Bank Name:_____________________________________________________________ Bank Address:___________________________________________________________ Other Information/Comments:___________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Statement of Verification: I hereby certify, to the best of my ability, that all of the information contained in this application is true and accurate. ______________________________________________ ___________________ Sign Name Date _________________________________________ ____________________________ Print Name Title/Position *Please submit this form along with your proposal, detailed budget plan, annual report (if available), and any other supporting documents you may deem important. Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
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Certification Regarding Terrorist Financing IMHO has procedures in place, in compliance with US laws on terrorist activities, to help ensure that no funds given by IMHO to any group or organization are diverted for purposes other than those specified in this application, especially with regards to the financing of terrorist activities. As a condition of entering into the referenced agreement, [enter applicant name]___________________ _____________________________________located at [enter applicant city, state, country of residence]_____________________________________________________, hereby certifies that it has not provided and will not provide material support or resources to any individual or entity that it knows, or has reason to know is an individual or entity that advocates, plans, sponsors, engages in, or has engaged in terrorist activity, including but not limited to the individuals and entities listed in the Annex to Executive Order 13224 and other such individuals and entities that may be later designated by the United States under any of the following authorities: Section 219 of the Immigration and Nationality Act, as amended (8 U.S.C. Section 1189), the International Emergency Economic Powers Act (50 U.S.C. Section 1701 et seq.), the National Emergencies Act (50 U.S.C. Section 1601 et seq.), or Section 212(a)(3)(B) of the Immigration and Nationality Act, as amended by the USA Patriot Act of 2001, Pub. L. 107‐56 (October 26, 2001)(8 U.S.C. Section 1182). [Enter applicant name]_____________________________________________________ further certifies that it will not provide material support or resources to any individual or entity that it knows, or has reason to know, is acting as an agent for any individual or entity that advocates, plans, sponsors, engages in, or has engaged in, terrorist activity, or that has been so designated, or will immediately cease such support if an entity is so designated after the date of the referenced agreement. For purposes of this certification, ‘material support and resources’ includes currency or other financial securities, financial services, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials. For purposes of this certification, ‘engage in terrorist activity’ shall have the same meaning as in Section 212(a)(3)(B)(iv) of the Immigration and Nationality Act, as amended (8 U.S.C. section 1182(a)(3)(B)(iv)). For purposes of this certification, ‘entity’ means a partnership, association, corporation, or other organization, group, or subgroup. This certification is an express term and condition of the agreement and any violation of it shall be grounds for unilateral termination of the agreement by DAI prior to the end of its term.
Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org
By signing hereon, the grantee certifies that the information provided in the grant proposal is accurate, current, and complete, that it understands and assents to the above statements, and that the grantee is aware of the penalty prescribed in 18 U.S.C. 1001 for making false statements. Applicant Name:_______________________________________________________________________ Signature:______________________________________________ Date:_____________________ Printed Name and Title/Position:__________________________________________________________
Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org